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Toby Knightley-Day: 'Nurses should take ownership of the Friends and Family Test'

22 January, 2013

Managers and frontline staff must start talking about the Friends and Family Test now, says Toby Knightley-Day

The Friends and Family Test (FFT) will ask accident and emergency and overnight inpatients whether they would recommend the services to their friends and family. In political circles it marks a step towards giving patients a meaningful voice and rewarding successful providers; for detractors, it has limitations - particularly its ability to deliver practical feedback. While there may be truth in both arguments, the longer people continue to rail against the measure, the less chance we have to make the compulsory FFT work for the NHS.

Criticism has focused on the score element of the test. To some degree this is understandable. Although a comparable score will allow the centre to measure system performance, in the past this has led to bureaucracy and little feedback for the frontline. It’s worth noting that in its original form, the FFT was a score linked to a text justification for that score. The problem is the government’s guidelines have allowed trusts the option of dropping this qualitative element, potentially leaving them with just a headline performance measure. For this reason, trust managers and frontline staff must start talking about the FFT now.

“It’s because nurses play a vital role in patient care that they are the key to the FFT’s success”

Andrew Frazer, chair of the RCN Emergency Care Association, said recently that the FFT represented another stick with which to punish staff. This was followed by comments by Sally Brearley, chair of the Nursing and Care Quality Forum (on whose recommendation the FFT was introduced), who rightly warned against focusing FFT results entirely on nurses (news, page 2, 4 December 2012). Both concerns stem from the same avoidable issue: implementing a score-only test. In this system, nurses will bear the brunt of complaints because they deliver the majority of hands-on care. Take, for example, the patient who waits hours for transport but is otherwise happy with their experience - their low score cannot be attributed to any specific cause, and it’s possible that the quality of care will become the scapegoat. If trusts decide against collecting qualitative feedback to explain scores, wards will be unable to deflect attention to the part of the system that is failing. Similarly, trust managers cannot hope to improve their scores if they cannot monitor and oversee improvement.

Instead of resisting, nurses could take ownership of the initiative. Although existing surveys feed into service development and policy, none connects individual experience with point of service in a way that encourages behaviour and culture change. If we let it, the FFT can bridge this gap. It’s because nurses play a vital role in patient care that they are the key to the FFT’s success. Own the measure, take pride in the scores, and strive to improve service according to patient feedback, and the NHS will benefit. Allow it to be an intrusive management tool that fails to empower you to make changes, and nothing positive will come from the compulsory investment.

By April, acute and emergency services will need to be operating the FFT. That means fewer than three months to decide on a format, appoint a provider, train staff and iron out issues. To get anything from the test, we must forget the aggregated score and encourage staff to use it to empower themselves. To do so, they must insist on a complete version of the test, including free text. Ward teams must set objectives and values, and should use feedback to ensure they meet them. Managers should then use qualitative data to reward success or identify issues and apply appropriate action. Only then can the test be more than a box-ticking exercise. Only then can we make timely interventions when care fails, or reward staff for going above and beyond expectations.

I think I at least partially agree with Toby - as I wrote on this site perhaps a week ago:

As it happens, there seems to be a potential 'golden window' during the next couple of years, in the run up to the election. Nurses could, I feel, combine several things: 1) The francis/Mid Staffs report is almost certain to highlight bad culture, nurses and patients not being properly listened to, and staff being bullied; 2) The Goverment is currently very keen on 'a culture of caring' and also on 'the Friends and Family test'; 3) nurses have got this concept of being advocates for patients, and that clearly hinges on the lengthier contact with patients that nurses have, compared to other clinicians.

So, why shouldn't nurses in our hospitals, write to their Chief Executives combining these 3 things, along the lines of 'Obviously front-line nurses are best placed to report back on whether or not our patients find this hospital's 'culture' good or bad, because patients talk to us most directly - so how is this hospital going to utilise the abilty and unique position of its nurses, to assess 'cultire' and contribute to its ongoing improvement ?'.

Made that up as I went along, but you get the idea - if such a letter dropped on the Chief Executive's desk, signed by 30% of a hospital's nurses, wouldn't the CE have to come up with some mechanism that actually empowered the nurses somehow ? The CE couldn't argue 'we don't value this 'culture' you mention', because that would be counter to Gov/DH policy !

I doubt it Mike. I've worked in trusts where the entire nursing staff have put in a vote of no confidence in the Director of Nursing and nothing much other than spin happened. CEOs have to deliver finance and performance targets and sadly many senior nurses may have a seat on the Board but don't have a vote.But the idea of nurses being involved in the design and use of this is a good one (once we get past the issue of capacity and time and yet another form to fill in) - but only if they see action taken. Bit like all the incident forms, sometimes it just feeds the beast. So if feedback was linked to more equipment or some sort of tangible change staff could see, then yes. Otherwise it's just a solution dreamt up in the ivory towers of Richmond House that make no sense in real life.

Of course we want our patients to feel happy with the care they receive!! We and, those we love, are patients too. As nurses, we want to leave duty knowing that we have been able to provide the very best care because we have had the right staffing levels, resources, good organisation and the time in which to do our work properly.

This FFT, is a piece of old sh*t. It cannot produce actionable results, because it is not set up to do so and the government/PTB are not interested in anything other than the deflection of 'blame'. I agree that this time in nursing (Mid staffs report, etc) is an opportunity for nurses to seize the moment and demand change, but not by embracing this pile of pants. It has gone way beyond another silly piece of paperwork.

Well said Mags ! As you know I am not shy about blasting the so-called "leadership" of our profession. Welcome aboard !

We just need to encourage a few thousand(s) of our colleagues to join in the chorus!

We need decent leadership ! A leadership which recognises the real problems not one that hallucinates about the magic effect of "C's" but one which cares for patients and will ensure that we are properly resourced to care!

There is a definite flavour of the day, that NHS services are to be assessed by patient experience as well as by easily measurable outcomes.

Nurses have this 'advocate for the patient' position, and if you ask 'well, aren't doctors also doing their best for patients ?', I think the obvious conclusion is that nurses have this advocacy role, because they interact most directly and often with the patient (amongst clinicians). So, while I do not want clinicians to design the feedback mechanisms necessarily (I would prefer the simple 'instruction' to patients and relatives 'Please tell us, if you think we are doing soemthing wrong'), I think logically it is almost impossible to deny that nurses are the best-placed clinicians to collect patient feedback 'in the round', and to pass this feedback upwards.

'once we get past the issue of capacity and time and yet another form to fill in'

I do not want, this feedback from patients to be 'form-based': I would like nurses to have 'an officially sanctioned role in collecting and passing on informally-gathered patient feedback': I would like nurses to be empowered to say 'We work with the patients, and having discussed what they are telling us nurses, many patients are not happy about ......'.

But yes, it does require a culture change, and yes it is about authority and decision-making (however, my proposal does not affect who eventually makes decisions - my suggestion, would be to introduce more transparency into the grounds on which decisions are based, and the problems considered important).

Instead of the 6 C's, I would like front-line nurses to act as 'Guardians of good culture' on an official basis: if nothing else, this would to some extent address the 'we are never listened to' complaint.

we are no longer really nursing, just glorified ad min assistants, we have no time to spend with patients as we are too busy form filling. If you lose your pen on the ward or your password, as a nurse you are now screwed. Nurses are very reluctant to loan anyone their pen. If your intranet connection goes down you will need to spend hours faffing about phoning IT. If you forget your numerous passwords, which have to be changed on a regular basis and have to get another one so you can get sorted to write up your notes more time wasting.

Patients don't really feature in the greater scheme anymore, it is just the stats and anyalysis and getting boxes to go green. I have tried to get all my boxes to go green on the British Intelligence (?oxymoron) report that our managers update us on weekly, we have a one hour meeting for that every week, but the computer says 'No', within its myriad of forms that i need to complete there must be one that i do not realise i need to do, no one can help me find it because there are so many forms and assessments attached to other forms and assessments that we can't find it amongst HONOS, Social Inclusion, clustering, clustering allocation, exit/entry referrals, demographics, CPA, care planning, core assesment, risk assessment, PBR, reviews, clinical documentation upload, best interests, MCA, INP, MMSE, Acer assessment, standard/enhanced score, to name but a few in the long list of forms that i have to complete once i have seen a patient. The form filling takes longer than seeing the patient.

Let's hope that the pendulum has swung to its full extreme and will soon settle back at centre as we need to get back to some sanity and end this continual form filling madness.

So long as the paperwork is completed the patients don't really feature in any of these reports (as we have been told).Unbelievable!

This was actually laughed at on The News Quiz. Look I don't prefer to go to an A&E department. If I actually need one, the ambulance will take me to the nearest one,=.

Does whoever thought of the question think we'll actually be able to choose: "Brighton's A&E looks nice. It has 5 stars. They give you chips and a nice runaround on the seafront once you have got better"

That would only work one way. Whereas, your average nurse could do a very sensible job of running the NHS, I think that the average politician would kill many patients (in a more direct way than usual).

I was thinking more of the big boys' (girls') stuff like the house of commons or the DH where I doubt nurses would do a very good job (although maybe far better in the latter than the former), although I agree the politicians would probably not fare very well with the patients.

Implicit in my comments was, that for this reason, I would like to see nurses giving their entire focus to their own job for which they are highly trained and desperately needed whilst leaving the politicians to do theirs but without either group meddling in the work of the other!

we all have to learn from our mistakes as well as those of others (if that is what you consider them) and move forward. there is little point in continuing to mull over what has already happened. what does time wasted on rumination achieve whilst more patients continue to suffer in the meantime?Hearing the same old story repeated over and over helps nobody.

I am thinking of starting a new web site EDadvisor or perhaps TripAdvisor will be willing to add Emergency Departments to their review and recommendation list next to the hotels and holiday resorts. It is a nonsensical question as you don't have much choice as to which ED you go to, except perhaps in some of the cities that have more than one (London and Bristol spring to mind). Would the commisioning service for your area actually pay up if you chose to go fifty miles to the ED recommended by your relative than the one that is five miles up the road? I don't think so.

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